The Sinking of the MV Doña Paz – I.

An analysis ofORIGINAL
theCASE
event REPORT
CASE REPORT
ARTICLE

The Sinking HeartofFailure

the MV and Short
Doña Stature
Paz in a 43 year-old
– A Critique on Maritime male Disaster
Katerina T.Preparedness
Katerina T. Leyritana
Leyritana11,, Ma. in the
Ma. Czarlota
Czarlota M. Philippines: an
M. Acelajado-Valdenor
Acelajado-Valdenor11 Analysis
,, Amado
Amado O. of the
O. Tandoc
Tandoc III Event
III22 and
and Agnes
Agnes D.
D. Mejia
Mejia11

Department
Department of
11
of Medicine,
Medicine, College
College of
of Medicine
Medicine and
and Philippine
Philippine General
General Hospital,
Hospital, University
University of
of the
the Philippines
Philippines Manila
Manila
Anthony
22 R. Perez,
Department
Department of
1 Carl Abelardo T. Antonio 2 and Rafael J. Consunji 3,4
of Pathology,
Pathology, College
College of
of Medicine,
Medicine, University
University of
of the
the Philippines
Philippines Manila
Manila

1Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery,

College of Medicine and Philippine General Hospital, University of the Philippines Manila
2Pasay City Health Office, Pasay City, Philippines

3Division of Surgical Critical Care and Trauma, Department of Surgery,

College of Medicine and Philippine General Hospital, University of the Philippines Manila
Presentation
Presentation4Study
of
of the
theGroup
case
case on Injury Prevention and Control,
require
require regular
regular
National laxative
laxative
Institutes use.
use. There
of Health,There was
was also
also aa report
report of
of two
two
This
This is
is aa case
case of
of aa 43-year-old
43-year-old male
male presenting
presenting with
with short
short more
more syncopal
syncopal
University of the Philippines Manila episodes.
episodes. He
He was
was brought
brought to
to another
another doctor
doctor
stature
stature and and heart
heart failure.
failure. The The patient
patient was was admitted
admitted at at the
the in
in aa private
private hospital
hospital wherewhere the the assessment
assessment was was still
still aa “heart
“heart
medicine
medicine ward ward of of the
the Philippine
Philippine GeneralGeneral Hospital
Hospital (PGH)
(PGH) problem”.
problem”. The The patient
patient was was againagain prescribed
prescribed unrecalled
unrecalled
for
for dyspnea.
dyspnea. This This paper
paper will will investigate
investigate several
several issues:
issues: medications
medications and and again
again was was lost lost to to follow-up.
follow-up. This This time,
time,
comprises. Given the vulnerability to harsh environmental
differentiating
differentiating congenital
congenital from from acquired
acquired hypothyroidism,
hypothyroidism, however,
however, symptomssymptoms were were persistent.
persistent. He He later
later consulted
consulted at at
conditions and our reliance on boats and ships for inter-
the
the relationship
relationship between between hypothyroidism
hypothyroidism and and the the another
another local local hospital,
hospital, where where he he was
was admitted
admitted and and managed
managed
island travel, Filipinos are somewhat resigned to the
cardiomyopathies,
cardiomyopathies, and and thethe therapeutic
therapeutic optionsoptions in in patients
patients as
as aa case
case of of anemia
anemia and and bronchial
bronchial asthma.asthma. He He was was discharged
discharged
numerous maritime accidents dotting the history of the
with
with cardiomyopathy
cardiomyopathy secondary secondary to to hypothyroidism.
hypothyroidism. slightly
slightly improved
improved after after four
four days,
days, only
only to to have
have recurrent
recurrent heart
heart
Philippine domestic shipping industry and their toll on
The
The patient
patient had had beenbeen born
born fullfull term
term to to aa then
then 31-year-
31-year- failure
failure symptoms,
symptoms, prompting prompting admission admission at at PGH.
PGH.
human life (Table 1).
old
old Gravida
Gravida 44 Para Para 33 (G4P3),
(G4P3), the the 44thth of
of 99 siblings,
siblings, with
with an an Upon
Upon admission
admission the the patient
patient was was in in mild
mild respiratory
respiratory
apparently
apparently unremarkable
unremarkable delivery delivery at at home
home facilitated
facilitated by by distress,
distress, with with stable
stable vital
vital signs
signs and and no no note
note of of fever.
fever. Pertinent
Pertinent
Table 1. Maritime disasters* in the Philippines (1980-2003)
aa traditional
traditional birth birth attendant.
attendant. He He was
was notednoted to to be
be normal
normal physical
physical exam exam findings
findings includedincluded short short stature,
stature, thick
thick lips,
lips, non-
non-
at
at birth.
birth. TheThe patient
patient was was allegedly
allegedly at at par
par with
with age
age both
both pitting
pitting
1980
periorbital
periorbital
M/V DON JUAN
edema,
edema, dry
dry skin,
skin, a
a displaced
displaced apical
apical
180 DEAD/115 MISSING
impulse,
impulse,
physically
physically and and mentally
mentally untiluntil eight
eight years
years oldold when
when he he was
was crackles
crackles
1981 on
on SAN
M/V both
bothJUANlung
lung fields,
fields, and and bilateral
bilateral non-pitting
non-pitting bipedal
52 DEAD bipedal
said
said to
to have
have stopped
stopped growing
growing in in height.
height. He He was
was brought
brought to to edema.
edema.
1986 There
There
M/V DOÑA was
was also
also aa 33 cm
JOSEFINA cm xx 33 cm cm reducible
reducible umbilical
150 DEAD umbilical
1987 However,
hernia.
hernia. M/V DOÑA there
However, PAZ
there was was no no pallor,
pallor, no > 4000
no neck
neckDEADvein
vein distention,
distention,
aa private
private doctor,
doctor, whose
whose diagnosis
diagnosis was was undisclosed,
undisclosed, and and he he
1988 M/V MARILYN 500 DEAD
was
was given
given medications
medications to to increase
increase height,
height, whichwhich the
the patient
patient no
no apparent
apparent
1994
congenital
congenital
M/V CEBU CITY
malformations,
malformations, no
no cardiac
cardiac
66 DEAD/ 76 MISSING
murmurs
murmurs
took
took for
for only
only oneone month
month with with no no improvement.
improvement. Through Through the the and
and
1995 no
no clubbing.
clubbing. There
There
M/V VIVA ANTIPOLO VII was
was also
also no
no note
note of
of
62 DEAD an
an anterior
anterior neck
neck
years,
years, thethe patient
patient waswas apparently
apparently well, well, although
although still
still of
of short
short mass.
mass.
1995 M/V KIMELODY CRISTY 17 DEAD/ 20 MISSING
1996 M/L GRETCHEN I 51 DEAD
stature,
stature, withwith thick
thick lips,
lips, coarse
coarse facial
facial features
features andand dry
dry skin.
skin. Laboratory
Laboratory workup
workupshowed showedcardiomegaly
cardiomegaly with
withpulmonary
pulmonary
1996 M/V DAVID JR. 7 MISSING
He
He was
was notably
notably slow slow in in ambulation.
ambulation. He He waswas said
said toto have
have congestion,
congestion,
1996 thoracic
thoracic
M/B NICKADEL dextroscoliosis,
dextroscoliosis, and
and atheromatous
atheromatous
4 MISSING aorta
aortaby by
bronchial
bronchial asthma
asthma at at age
age 1515 years,
years, and
and since
since then
then he
he had
had been
been chest
chest
1996 radiograph,
radiograph,
M/V PENAFRANCIA and
and left left ventricular
ventricular hypertrophy
hypertrophy
2 THROWN OVERBOARD by
by 12-lead
12-lead
taking
taking salbutamol
salbutamol tablets
tablets occasionally
occasionally for for bouts
bouts ofof dyspnea
dyspnea electrocardiogram
electrocardiogram
1997 M/B FISH HUNTER (12-L
(12-L ECG) ECG) (Figures
(Figures 11 and
3 DEADand 2), 2), normocytic
normocytic
1997 F/B ANNIE PAULINE 4 MISSING
occurring
occurring one one toto two
two times
times annually.
annually. normochromic
normochromic anemia anemia (Hgb (Hgb 90 90 mg/dL),
mg/dL), dyslipidemia,
dyslipidemia, and and
1997 M/V KALIBO STAR 17 DEAD/ 13 MISSING
The
The patient’s
patient’s symptoms
symptoms started started in in 2001
2001 when
when he he waswas pre-renal
pre-renal
1998 azotemia
azotemia (serum
(serum
M/V PRINCESS OF THE ORIENT creatinine
creatinine 123
123 mmoL).
mmoL). Electrolytes
Electrolytes
70 DEAD/ 80 MISSING
reported
reported to to have
have sudden
sudden loss loss of of consciousness.
consciousness. During During this this on
on1999admission
admission
M/V ASIAshowed
showed
SOUTH KOREA slight
slight hyponatremia,
hyponatremia,
58 DEAD hypokalemia,
hypokalemia,
time,
time, the
the patient
patient diddid notnot have
have any any symptoms
symptoms of of heart
heart failure;
failure; and
and
2001hypochloremia
hypochloremia
M/L ANNAHADA (serum
(serum Na Na 136,
136, K K 3.35,
3.35, Cl
Cl 86).
124 DEAD/ 86).
14 Blood
Blood gases
MISSING gases
2002 M/V MARIA CARMELA 39 DEAD / 6 MISSING
no
no prior
prior seizures,
seizures, cyanotic
cyanotic episodes,
episodes, chestchest pain,
pain, headache,
headache, or or revealed
revealed
2002
partially
partially
M/V NILODE- A
compensated
compensated metabolic
metabolic alkalosis
alkalosis
19 DEAD
with
with mild
mild
blurring
blurring of of vision.
vision. He Introduction
He regained
regained consciousness
consciousness shortlyshortly after
after and
and hypoxemia.
hypoxemia.
2003 The
The patient
M/V SAN NICHOLASpatient was
was noted
noted to
to be
be hypothyroid
hypothyroid
43 DEAD/ 21 MISSING based
based
was The
was brought
brought Philippines
to
to aa private
privateis physician,
a maritime
physician, whose
whose country by force
assessment
assessment wasofaa
was on
on elevated
elevated serum serum thyroid-stimulating
thyroid-stimulating hormone hormone (TSH) (TSH) and and
geography owingHe to was
its archipelagic layout. Hundreds of *Maritime
markedly
markedly disasters refer to events
decreased
decreased serum
serum occurring
free at sea that result
free thyroxine
thyroxine to “aThe
(FT4).
(FT4). mismatch
The exact
exactof
“heart
“heart problem”.
problem”. He was prescribed
prescribed unrecalled
unrecalled medications
medications
casualties seeking medical care and the availability of such care.” (Eischen J. Maritime
ferries
taken
taken for carry
for many
aa few
few thousands
months
months and of working
and eventually
eventually people and when
discontinued
discontinued rural
when values
values are
disasters. areHogan
In: shown
shown DE, in
in Tables
Tables
Burstein 11 and
and
JL, eds. 2.
2. medicine, 2nd ed. Philadelphia, PA:
Disaster
the
the syncopal
poor syncopal
between episode
episode
the moredid
did not
not recur.
recur.
than 7,000 islands the country Upon
Upon
Lippincott admission
admission
Williams & Wilkins;to
to2007.
the
the pp.wards,
wards,
332-338.)the
the patient
patient was was managed
managed
In
In the the next
next fourfour years,
years, the the patient
patient would would develop
develop as
as having
having congestive
congestive heart heart failure
failure from from cardiomyopathy
cardiomyopathy
_______________
intermittent,
intermittent, progressive
progressive exertional
exertional dyspneadyspnea and and bipedal
bipedal secondary
secondary
On theto to morning
acquired
acquired of hypothyroidism.
hypothyroidism.
December 21, Oral Oral
1987,loop
loop
thediuretics,
diuretics,
Filipino
edema.
edema. LaterLater on on this
this would
would be be accompanied
accompanied by by generalized
generalized angiotensin-converting
angiotensin-converting
people were given a rudeenzyme enzyme
awakening (ACE)
(ACE) wheninhibitors,
inhibitors,
the news broke beta-
beta-
body
body weakness,
weakness, anorexia,
anorexia, and and constipation,
constipation, severesevere enough
enough to to blockers,
blockers,
that the livesstatins,
statins,of and
and
more levothyroxine
levothyroxine
than 4,000 people were
were started.
started.
hopingElectrolyte
Electrolyte
to spend
correction
correction in
Christmas was
was instituted.
instituted.
Manila were lost The
Theforever
sections
sections in aof
ofseaEndocrinology
Endocrinology
of fire off the
Corresponding author: Anthony R. Perez, MD
Department of Surgery and
and Cardiovascular
Cardiovascular Diseases
Diseases
coast of a remote province in Mindoro. The were
were co-managing
co-managing the
theensuing
patient
patient
Corresponding
Corresponding author:
author: Ma.
Ma. Czarlota
Czarlota Acelajado-Valdenor,
Acelajado-Valdenor, M.D.
M.D.
Philippine General Hospital
Department
Department of of Medicine
Medicine together
together with
with the
the General
General Medicine
Medicine
response from concerned agencies focused on finger service.
service.
University of the Philippines Manila
Philippine
Philippine General
General Hospital
Hospital He
He soon
pointing, soon developed
developed
putting the blame respiratory
respiratory failure,
failure, upon
on organizations upon which
whichwith
concerned the
the
Taft Avenue, Ermita, Manila 1000 Philippines
Taft
Taft Avenue,
Avenue, Manila,
Manila, 1000
Telephone: +639209703622
1000 Philippines
Philippines considerations
considerations were
were acute
acute pulmonary
pulmonary
safety and enforcing regulations governing the Philippine congestion,
congestion, nosocomial
nosocomial
Telephone:
Telephone: +632
+632 554-8488
554-8488 pneumonia,
pneumonia, to
to rule
rule out out an an acute
acute coronary
coronary event.
event. He
HeHouses
was
was later
later
Email: tonyperez92@yahoo.com maritime industry. Several bodies, including both of
Email:
Email: czarlota@yahoo.com
czarlota@yahoo.com

12
12 ACTA
28 ACTA
ACTA MEDICA
MEDICA
MEDICA PHILIPPINA
PHILIPPINA
PHILIPPINA VOL.
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VOL. 43
43NO.
N0.
N0. 434 2009
2009
2011
 The Sinking ofHeart Failure
the MV DoñaandPaz
Short
– I.Stature in a 43 year-old
An analysis male
of the event

Table 1. Initial
Congress Laboratory
displayed Results
extraordinary eagerness to conduct controlling the majority of the shipping industry in the
hearings on the sensational issue in front of national media. Philippines. It had a declared capacity of 1,518 passengers
CBC Blood chem. Urinalysis ABG
Proposals to improve maritime safety by enforcing the and was manned by a crew of 60.1 It was acquired by
implementation Reference Result
of strict standards were banneredReference
by Result
Sulpicio Lines in Color
1975.8 straw pH 7.408
Value Value
legislators
WBC and
5-10
concerned organizations
4.5 RBSimmediately after
3.9-6.1 6.3The steel-hulled,
Transp 629-ton MT Vector,
Clear pCO2the other 49.1 ship
the incident. 4-6
RBC HGBA1C 4.27-6.07 involved
6.4 in theSpaccident,
Gravity carried 1.010a crew ofpO2 13. At the time 70 of
HGBThe reality BUN
is that months90after the incident
120-150 interest2.6-6.4
died the5.0incident, the pH Vector was on 8.0lease toHCO3 31.3
Caltex Philippines,
HCT with families
down, 0.38-0.48 of the victims CREA or with53-115
0.27 left without only 123 with transporting
tasked Sugar itsNEG cargo ofO2 9,000
sat 93.6 of
barrels
MCV 80-100 FL ALB 34-50 32 Protein NEG FiO2 21% 5,8
minimal compensation, with blame being put on agency gasoline, kerosene and crude oil from Bataan to Masbate.
MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
officials
MCHC not capable
320-360 G/Lof defending themselves.
HDL Questions on
0.91-1.56 Most of the WBC
0.67 vessels plying0-2the major Filipino domestic
the
RDWeffectiveness of
11.5-15.5% the proposed measures
LDL were quickly
1.1-3.8 shipping
4.21 routes areCastsecondhand cargo and passenger PBS ships
PLT
answered 200-400
when Inc
another passenger TOTAL
ship, theCHOL 4.2-5.2
MV Marilyn 5.25 cheap Epith
bought fromcellJapaneseRare shipyards,Slight poikilocytosis,then
which are
RETIC
belonging to 0.005-0.015
the same shipping company AST (Sulpicio Lines),
15-37 95
reconditioned Bacteria
in local shipyards,Occ’l given new names
acanthocytes, and
ovalocytes,
SEG 50-70% 48 ALT 30-65 91 Mucus th Rare
also sank, killing hundreds of innocent people a year later. advertised as luxury passenger liners. slight toxicseven
All the granulation,
major
LYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
This first2-9%
MONO of two papers2 will dissect NA and analyze140-148
the liners
136.9(SulpicioAm Lines,
uratesSweet Lines, Aboitiz Shipping Corp,
circumstances
EO 0-4% leading to, 0 during, K and immediately
3.6-5.2 Hijos
3.35 de Escano Inc., Negros Navigation, Carlos Gothong
BASO
following, the0-2%
worst peacetime 0 maritimeCL 100-108
disaster in modern 86 and William Lines Inc.) maintain ships with an
Lines,
BLAST CA++
history, in 0% 0
the process reconstructing the events2.12-2.52
as 2.37
average age of 22 years, with 20% of these more than 30
P 2.27
accurately as possible. A comprehensive MG++understanding of
0.74-1 years
0.83old. According to shipping companies, procurement of
the incident, the factors contributing to the tragedy, the new ships coupled with high maintenance costs and low
immediate response to the tragedy and the acute medical revenues will render business non-viable.1
care provided to the victims will lead to recommendations In the Philippines, water transportation is still the best
for improving fat
mode pad. of Cardiac enzymes
cargo carriage and were not consistent
transport between with
its morean acute
than
Table 2. Thyroidour preparedness
Function Tests to deal with and prevent
similar catastrophes in the future. coronary event (Table 3), however, intravenous
7,000 islands. Passengers traveling both for business (IV) heparin
and
Reference Value Result (overlapping with orallocations
warfarin)within was still
Free T4 (0.8-2.0) 0.02 ng/dL pleasure to various thegiven to coverstill
archipelago for
Methods the presence of a possible LV thrombus
favor water travel due to lower fares and unlimited baggage as demonstrated
TSH (0.4-6.0) 24.75 Uiu/ml
A comprehensive search and review of all available by rheologic
allowances, stasis on
especially when cardiac
compared ultrasound. Medications
with air travel.
records on the sinking was performed. Relevant published wereThe shifted
travel conditions along the routes being pliedwas
to IV diuretics and inotropes; oral digoxin by
materials regarding the events were gathered including started. IV
these ships can antibiotics
best be were
described givenasfor possible pulmonary
unpredictable, at worst
infection.
hazardous. TheInpatient
many later
partsonof showed improvement,
the country, typhoons and wasand
newspaper articles from the most widely distributed daily
eventually weaned off from ventilatory support, extubated,
newspapers that extensively covered the incident. A formal hurricanes regularly batter shipping lanes. The maritime
request was made to the Philippine Daily Inquirer, and the industry often has to rely on weather advisories from
authors were given access to several archived articles on the Table
government3. Cardiac Enzymes
agencies with aging and obsolete forecasting
incident.1,2,3,4 Official reports from agencies concerned with equipment, the batting average
Reference Rangeof which can be
(mmoL) described as
Result
the accident were secured and reviewed when available. A inconsistent
Qualitative at best. This is compounded by inadequate
POSITIVE
formal request from the MARINA office allowed the authors dissemination
Troponin I of available accurate weather forecasts. Other
to secure a copy of the report, "MARINA Report on the Doña CK-MB
aids to navigation appear 0-6.0
to be equally inadequate. 1.14 Of the
Paz Tragedy".5 Proceedings from congressional hearings CK-TOTAL 21-232 543
308 lighthouses lining the 36,289 km coastline, less than half
were secured through the Senate Secretariat’s Office are operational. Only 42 of the 120 charted buoys in
Websites of government agencies concerned with the Philippine waters are in position. Government navigational
maritime industry were accessed and searched for relevant charts have not been updated since 1980 to reflect present
information.6 sea conditions, such as vessel wreckage and non-functional
Figure 1. Electrocardiogram
A direct interview with upon admission
a survivor and another victim's lighthouses. The numerous vessels plying these routes have
relative were conducted. Documentaries produced by to rely on many occasions on the crewmen’s experience and
National Geographic7 and GMA News Network8 were also instinct, referred to as “dead reckoning”. The Doña Paz and
transferred to the intensive care unit (ICU) for ventilatory
reviewed. the Vector set out on their respective voyages armed only
support and closer monitoring. On bedside cardiac ultrasound,
A thorough review and cross referencing of the above with these navigational tools, as had always been the case in
there was a finding of eccentric left ventricular hypertrophy,
sources of information were conducted to reconstruct the the numerous trips they had taken.5
global hypokinesia with depressed overall systolic function
circumstances surrounding the incident. Several government agencies and institutions oversee
with concomitant spontaneous echo contrast on left ventricular
the Philippine maritime industry and each has its own set of
(LV) cavity suggestive of rheologic stasis, the ejection fraction
Results and Discussion operating procedures. For every ship and every sailing,
was 25%, with moderate mitral regurgitation, moderate
aortic regurgitation with The
Pre-disaster Events. aorticMV Doña Paz
sclerosis, wastricuspid
severe a steel- clearances have to be obtained from at least eight agencies,
hulled liner built in 1963 weighing 2,215 tons
regurgitation with mild pulmonary hypertension, pulmonary and was including the Philippine Ports Authority (PPA), Bureau of
owned by Sulpicio Lines, one of seven major companies
regurgitation, and minimal pericardial effusion or pericardial Customs
Figure (BoC),radiograph
2. Chest Bureau of on Posts (BoP) and Bureau of Plant
admission

VOL. 45
VOL. 43 NO.
N0. 432009
2011 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHILIPPINA 29
13
The Sinking of the MV Doña Paz – I. An analysis of theCASE
event REPORT

Industry (BPI). Inspection Heart by the Failure and Short

National Quarantine OfficeStatureis also in a 43 toyear-old
expected male and prevent pirates,
constantly intercept
is aimed at ensuring sanitary conditions inside passenger terrorists and rebels from taking advantage of the country’s
ships.Katerina
6
T. Leyritana1, Ma. Czarlota M. Acelajado-Valdenor porous1, Amado
coastlines O.toTandocengageIIIin 2
and Agnes D. of
a multitude Mejia
nefarious
1

The Philippine Coast Guard (PCG) is tasked to inspect activities.6

the ships yearly 1
Department
to ensure of Medicine,
theirCollege of Medicine
safety. Ships and Philippine General
found Hospital,
Such wereUniversity of the Philippines
the conditions of the Manila
Philippine Maritime
seaworthy are issued certificates
2
Department of Pathology,
of inspection, College
while of Medicine,
those University
Industry of theboth
when Philippines
the Doña Manila
Paz and the Vector set out from
found unseaworthy are taken to the docks for repairs. The their respective points of origin. Though the history of the
Doña Paz, at the time of her last voyage, was said to have all water travel in the Philippines has always been marked by
the necessary inspection papers from all these agencies. The mishaps and accidents, both manmade and natural, never
Vector, on its last PCG inspection, was found to have a had a tragedy of this magnitude and human toll ever
steering defect and some other deficiencies. Based on occurred in the history of civilian shipping.
available documents, Presentation of the case
its radio license had expired nearly 18 require regularEvents.
Disaster laxative Onuse. There was
December 20,also1987, a report
peopleoffrom two
This is
months a caseItofsailed
earlier. a 43-year-old
withoutmale presenting
a certificate of with short
inspection more
Samarsyncopal
and Leyte episodes. He was brought
and various areas from to another doctor
the southern
stature
and the and
papersheart failure. The
it submitted patient
to the Coast was admitted
Guard at the
were found in a private were
Philippines hospital where
joining thethemad assessment
rush to board was thestillDoña
a “heartPaz
medicine
to be fake.5,8 ward of the Philippine General Hospital (PGH) problem”.
on its voyage The patient hoping
to Manila, was again to joinprescribed
their families, unrecalled
others
for dyspnea.
Seamen in Thisthepaper will investigate
Philippines are licensed several by issues:
the medications
bringing their andfamilies
again was to the lostbigto city,
follow-up.
in time Thisfortime,
the
differentiatingRegulation
Professional congenitalCommission,
from acquired as arehypothyroidism,
all crewmen however,
Christmassymptoms
holidays. Itwere was persistent. He later
set to sail from consulted
Tacloban City inat
the relationship
plying Philippine waters betweenand manninghypothyroidism
international and the
vessels. another
Samar tolocal hospital,
Manila. The 675 where he was
people whoadmitted
boardedand the managed
Doña Paz
cardiomyopathies,
The Philippines in and fact the therapeutic
controls nearly options
20 percentin patients
of the as a case of anemia
in Tacloban were alland listedbronchial asthma. He
in its passenger was discharged
manifest. Another
with cardiomyopathy secondary to hypothyroidism.
officer and rated positions in the world’s fleet with more slightly improved after four days, only
908 boarded the liner when it stopped in Catbalogan to have recurrent toheart
pick
The patient had been born full
than 180,000 seafarers. It is said that among seafarers term to a then 31-year- failure symptoms, prompting admission
up more passengers. The declared number of passengers at PGH.
old GravidaFilipinos
worldwide, 4 Para 3have (G4P3),
the mostthe 4training,
th
of 9 siblings,
assessment withand an wasUpon
placedadmission
at 1,583, alongthe patientwith a wascrewin of mild
58. The respiratory
declared
apparently unremarkable delivery at
certification. It is a valid premise that the crewmen of both home facilitated by distress, with stable vital signs and
capacity of the Doña Paz was only 1,518 passengers no note of fever. Pertinent
and 60
a traditional
ships were part birth attendant.
of this trained group.He was 2 noted to be normal physical exam findings
crew members; based on included
the listed short stature, thick
passengers alonelips,
the non-
ship
at birth. The patient
The Philippine was allegedly
Rescue Coordinating at par
Centerwith(PRCC),
age both as pitting periorbital
was already loaded edema,
beyond dry skin, a displaced
its capacity andapical impulse,
it should not
physically internationally,
mandated and mentally until is the eight
leadyearsagency oldwhen
whenmaritime
he was crackles
have been onallowed
both lung fields, and
to proceed bybilateral
the Coast non-pitting
Guard and/or bipedalthe
said to haveoccur.
disasters stopped Although
growing in height. the NationalHe was brought Disaster to edema.
shippingThereline wasandalso its acrew.
3 cm x 3 cm reducible
Accounts umbilical
from survivors,
a private doctor,Council
Coordinating whose diagnosis was undisclosed,
is responsible and he
for disaster hernia.
however, However,
described there was packed
a ship no pallor, tonotheneck vein distention,
railings, four deep
was given medications to increase
management during natural or manmade calamities, the height, which the patient no apparent congenital malformations,
in the bunks with no place to move in the common no cardiac murmurs
areas.
took for only one month with no improvement.
PRCC is tapped for its technical competence in handling Through the and no clubbing. There was also no note
Others claim that the ship was visibly listing to one side, of an anterior neck
years, the patient was apparently well, although
aeronautical and maritime disasters. It has at its disposal the still of short mass.
even before it left its moorings in Tacloban; a visual
stature, with
resources of thick lips, coarseAir
the Philippine facial
Force features
for itsand dry skin.
Search and Laboratory
testament to itsworkup
state ofshowed
overload. cardiomegaly
8 At the points withofpulmonary
boarding,
He was notably slow in ambulation.
Rescue (SAR) operations. This is where the Air Force plays a He was said to have congestion,
hundreds more came aboard as the ship was leavingaorta
thoracic dextroscoliosis, and atheromatous port.by It
bronchial asthma at age 15 years, and
vital role, along with the Navy through the Coast Guard. since then he had been chest radiograph, and left ventricular hypertrophy
was estimated by those on board that the Doña Paz left port by 12-lead
taking from
Aside salbutamol tablets occasionally
these resources, the PRCCfor canbouts of dyspnea
tap planes and electrocardiogram
with around 3,000 (12-L to 4,000 ECG) (Figures 1Accounts
passengers. and 2), normocytic
from those
occurring one to two times annually.
choppers of the US Air Force stationed in the country tasked normochromic anemia (Hgb
with experience with other liners confirm 90 mg/dL), dyslipidemia,
that in and the
The patient’s
to assist symptoms when
in civil emergencies started they in occur.
2001 9when he was pre-renal
Philippines,azotemia (serum creatinine
discrepancies between the 123 manifest
mmoL). Electrolytes
and actual
reported
Of the to numerous
have sudden loss of consciousness.
government agencies concerned Duringwith this on admission
passenger load showed
easily runslight up to hyponatremia,
thousands. hypokalemia,
time, the patient did not have any symptoms
making policies and overseeing the Philippine maritime of heart failure; and hypochloremia (serum Na 136, K
The difference will be accounted for by several3.35, Cl 86). Blood gases
factors.
no prior seizures, cyanotic episodes,
industry, none play a more direct and important role thanchest pain, headache, or revealed
Children are usually not listed in the manifest. On mild
partially compensated metabolic alkalosis with this
blurring of vision. He regained consciousness
the PCG. Although some agencies overlap its functions, it is shortly after and hypoxemia.
particular trip,Thehundreds
patient was noted toexcited
of children, be hypothyroid based
to go to Manila,
was brought
concerned to amaritime
with private physician,
security, maritimewhose assessment was a
safety, maritime on
wereelevated
broughtserumalongthyroid-stimulating
by their parents. It hormone (TSH) and
is an acknowledged
“heart problem”. He was prescribed unrecalled medications markedly decreased serum free thyroxine (FT4). The exact
environmental protection and maritime search and rescue. practice that tickets to the ships are sold by scalpers, and this
taken for a few months and eventually discontinued when values are shown in Tables 1 and 2.
Aside from doing its part in enforcing rules and regulations trip was no different, with many trying to get valuable slots
the syncopal episode did not recur. Upon admission to the wards, the patient was managed
to ensure the seaworthiness of vessels carrying passengers for the Doña Paz.3
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
and cargo, it has the enormous responsibility of patrolling The Vector, with its crew of 13, set out to sea from
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. Oral loop diuretics,
Philippine sea waters. This entails monitoring 500,000 square Batanes, carrying 9,000 gallons of petroleum products
edema. Later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
miles of territorial waters and a coastline twice that of the including gasoline, kerosene and oil. The most senior
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
United States. As is the case with other government agencies navigator on deck serving as captain was a seafarer with a
correction was instituted. The sections of Endocrinology
severely hampered by limited resources, the PCG has very license of 2nd mate. The crew, as is customary during long
and Cardiovascular Diseases were co-managing the patient
meager equipment
Corresponding author:given the taskAcelajado-Valdenor,
Ma. Czarlota at hand. The PCGM.D. only has holidays in the Philippines, was already in a festive mood,
Department together with the General Medicine service.
two search of Medicine
and rescue cutters and 23 World War II-vintage drinking and merrymaking during the trip.
Philippine General Hospital He soon developed respiratory failure, upon which the
boats for patrolling a very large area. Not only does it have Based on available accounts of the incident, there were
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
to contend+632
Telephone: with vessels with questionable seaworthiness, it
554-8488 no reported weather disturbances at the time the Vector and
pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
30 ACTA MEDICA PHILIPPINA
PHILIPPINA VOL.45
VOL. 43NO.
N0. 43 2009
2011
 The Sinking ofHeart Failure
the MV DoñaandPaz
Short
– I.Stature in a 43 year-old
An analysis male
of the event

Table
the Doña1. Initial
Paz Laboratory
crossed paths Resultsat Tablas Strait, 40kms from such as this, a full eight hours after the collision. Details
Oriental Mindoro and about 175kms from Manila. Much of from secondhand information were allegedly insufficient
CBC Blood chem. Urinalysis ABG
what happened can be reconstructed from accounts of the and thus, a search and rescue operation was not initiated at
Reference
survivors andReference
those within theResult vicinity of the incident. Those thisResult
point. After Color
another eight straw
hours, pH information 7.408
was
Value Value
who
WBCwere awake 5-10
at the time 4.5
of the RBSincident heard an
3.9-6.1 deemed
6.3 adequate and
Transp the PCG, Philippine
Clear pCO2Air Force 49.1 US
and
explosion
RBC that4-6jarred the Doña Paz. One HGBA1C survivor claimed to
4.27-6.07 Air6.4 Force were Sp Gravitymobilized. 1.010 US choppers pO2 and
70 a
HGB
had just talked to the captain 90
120-150 and the chief BUN mates of the 2.6-6.4
Doña 5.0
reconnaissance pH that arrived
plane 8.0 first at HCO3
the scene 31.3initially
HCT
Paz who were0.38-0.48
drinking liquor0.27 at a party CREA
on the bridge a53-115few 123 to locate Sugar
failed the site. They NEG later noted O2 satan area93.6 where
MCV 80-100 FL ALB 34-50 32 Protein NEG FiO2 21%
minutes before the explosion. Upon going up the deck, debris was floating all around, with no survivors in sight.
MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
survivors
MCHC saw the ocean
320-360 G/L turn into a seaHDL of flames. Many of
0.91-1.56 All0.67
vessels and aircraft
WBC arrived0-2 at the point of the collision at
those
RDW who survived11.5-15.5% can only recall jumping
LDL into the water,
1.1-3.8 least
4.2116 hours later,Castlong after both ships had sunk. PBS
PLT
leaving behind200-400people wailing Inc TOTAL CHOL in 4.2-5.2
and screaming pain. 5.25 Epith celldespite Rare
The Don Claudio, having practically nonexistent
Slight poikilocytosis,
RETIC
Children’s cries echoed in the night. A AST
0.005-0.015 man who was 15-37 with 95
medical Bacteria
supplies, was able Occ’l to safely acanthocytes,
bring all of the 26
ovalocytes,
SEG 50-70% 48 ALT 30-65 91 Mucus th Rare
his family was awakened by the loud explosion while survivors they rescued from the siteslight to toxic granulation,
Manila North
LYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
sleeping
MONO in one 2-9% of the bunks of 2 the DoñaNA Paz. He went to the
140-148 Harbor,
136.9 175 kilometers
Am urates from the area of the collision even
cabinet
EO containing
0-4% the life vests0 only to find
K them locked. He
3.6-5.2 before
3.35 an organized, credible search and rescue operation
BASO into0-2%
jumped the burning waters 0 to CL
escape the flames 100-108 was86mounted. Waiting at the harbor were a few ambulances
BLAST 0 knowingCA++ 2.12-2.52 2.37
engulfing the0%Doña Paz, never what happened to sent by those who received calls from the Don Claudio. The
P 2.27
his wife and two daughters who accompanied MG++ him on0.74-1
the survivors
0.83 who were able to walk and had no gross signs of
trip to Manila. One survivor remembers seeing people injury made their own arrangements for transportation.
burning afloat on the open seas, with many others Some were picked up by relatives, others took taxis while
swimming and shouting the names of relatives and crying those having nowhere to go stayed for a long period of time
out for2.help. fat pad. Cardiac
waiting for theenzymes were notofconsistent
Department with an acute
Social Welfare and
Table Thyroid
4
Function Tests
Evidence gathered by subsequent inquiries concluded coronary event (Table 3),
Development (DSWD) to assist them. however, intravenous
4 (IV) heparin
Reference Value Result (overlapping with oral
that T4 Vector rammed
Freethe the port side of0.02
(0.8-2.0) Doña Paz,
theng/dL The survivors whowarfarin)
had gross wassigns
still given to cover
of injuries for
were
immediately disabling the engine and setting the presence of a possible LV thrombus as demonstrated
TSH (0.4-6.0) 24.75the two ships
Uiu/ml brought individually to various hospitals in Manila and
on fire. Both ships sank in about 545 meters of shark-infested by
wererheologic
treated stasis
for burn on injuries.
cardiac ultrasound.
Some were Medications
brought to
waters within a matter of minutes. The crew of the ship were shifted to IV diuretics and
Metropolitan Hospital, others to San Juan de inotropes; oralDios
digoxin was
Hospital
sailing within a few miles of the collision heard a loud started. IV antibiotics were given for
and Jose Reyes Memorial Medical Center. No listing of the possible pulmonary
explosion and a ball of fire towering several hundred meters infection.
survivors The whopatient
required later on showed
medical improvement,
treatment and was
could be obtained
eventually weaned off from ventilatory support, extubated,
was seen. It will never be ascertained what transpired on the from government agencies involved in the management of
bridge of the Doña Paz and the Vector right before the this accident.4
incident. It is likewise acknowledged that no distress call TableThe 3. Cardiac Enzymes
subsequent government response to this tragedy
was sent from the radios of either vessel. No one received involved mainly retrieval operations
Reference Range (mmoL)for the Resultmany corpses
the SOS call, if ever there was one. The answer went down left at sea.
Qualitative Hundreds of bodies washed POSITIVE on the
ashore
along with all 58 crewmen of the Doña Paz, and 11 of the 13 coastlines
Troponin I of Oriental Mindoro, leaving the local villagers
seafarers on board the Vector. The two survivors from the CK-MB
with the grim task of spraying0-6.0 1.14
them with sanitizers and
CK-TOTAL 21-232 543
Vector never had an inkling of the imminent collision.5 covering them up with makeshift structures to minimize the
The MV Don Claudio, a cargo ship plying a route smell. Some were forced to bury the dead without having
bringing it close to the scene of the collision, witnessed the them identified to prevent them from rotting near houses
explosion and the ball of fire lighting up the sky. They lining the shore. Outbreaks of diarrhea and respiratory
reached the scene within a few hours of the collision but illness were noted in these villages. The Coast Guard
Figuresaw
never 1. Electrocardiogram
either of the two ships. upon admission
Debris was all around the enlisted the help of banca (boat) owners, shipping
ocean and they searched for survivors. They were able to companies and private boat operators to help them in the
rescue 26 people, 24 of them were passengers of the Doña retrieval operations. A little over 500 bodies were
transferred to the intensive care unit (ICU) for ventilatory
Paz and two were from the Vector. This act of heroism was subsequently recovered and many were left unidentified.
support and closer monitoring. On bedside cardiac ultrasound,
the only bright spot in this tragedy, for subsequent search The true number of casualties to this day remains unknown
there was a finding of eccentric left ventricular hypertrophy,
and rescue operations would only confirm the magnitude of as thousands remain entombed in the Doña Paz and its
global hypokinesia with depressed overall systolic function
the tragedy, with the recovery of hundreds of bodies and environs.
with concomitant spontaneous echo contrast on left ventricular
leaving behind thousands more trapped in the depths of Initial public reaction to the incident was one of extreme
(LV) cavity suggestive of rheologic stasis, the ejection fraction
Tablas
was 25%, Strait. 5
with moderate mitral regurgitation, moderate outrage towards Sulpicio Lines. Relatives of the casualties
aorticPost-disaster
regurgitation Events.
with News
aortic of the collision
sclerosis, severereached the
tricuspid lined up outside the offices of Sulpicio Lines crying for the
Philippine Rescue Coordinating Council
regurgitation with mild pulmonary hypertension, pulmonary (PRCC), the lead heads of officials. Sulpicio Lines immediately blamed Caltex
government
regurgitation,agency tasked pericardial
and minimal to handle maritime
effusion oremergencies
pericardial Philippines
Figure forradiograph
2. Chest contracting the Vector to carry highly
on admission

VOL. 45
VOL. 43 NO.
N0. 432009
2011 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHILIPPINA 31
13
The Sinking of the MV Doña Paz – I. An analysis of theCASE
event REPORT

dangerous cargo on aHeart Failure and

grossly inadequate and Short Stature
unseaworthy in a 43disaster
other maritime year-old incidents male dotting the long maritime
vessel. history of the Philippines.
Katerina
The various T. Leyritana
branches 1,ofMa. theCzarlota
government M. Acelajado-Valdenor
initiated The
1
, Amado
tragedy O. of Tandoc
the DoñaIII Paz and Agnes D. Mejia1
2 sinking may have resulted

separate inquiries into the accident and independently from ships of questionable seaworthiness being manned by
released their findings.
1
Department Theof Board
Medicine, of College
Marine of Inquiry,
Medicine and Philippineless-than-qualified
Senate General Hospital, University of the Philippines
mariners. TheseManila factors were
Committee on National Defense,
2
Department
Coast of Pathology,
Guard andCollege
Congress of Medicine, University of the
compounded byPhilippines
an archaic Manilacommunication system that
all conducted investigations. A congressional probe contributed to the delay in response. This delay, along with
committee declared that both the Doña Paz and the Vector the perennial problem of overloading of passengers and
should be blamed for the collision. After conducting 13 inadequate medical response, contributed immensely to the
public hearings and listening to the testimony of 55 expert unprecedented loss of lives.
witnesses, the committee concluded that the crewmen Strict enforcement of existing laws and formulation of
manning both ships Presentation of the case
were not qualified to do so. They also require
new ones regularmaylaxative
prevent use.future
There maritime
was also aaccidents
report of two and
This
cited is agovernment’s
the case of a 43-year-old overall male apathy presenting
toward with the short
local more
decreasesyncopal
morbidityepisodes. He was brought
and mortality when such to another
events doctor
occur.
stature and
maritime heart failure.
industry as the The real patient was admitted
culprit behind at the
the collision. in
Thea private
shipping hospital
industry where mustthe assessment
exert an effort was still a “heart
to upgrade
medicine
The Marine ward
Board of oftheInquiry
Philippine reportGeneral
put the Hospital
blame squarely (PGH) problem”.
vessels andThe patient was
equipment, andagainimprove prescribed
complianceunrecalled
with
for the
on dyspnea.
Vector. This
Basedpaper on their willreconstruction
investigate several of events, issues:
the medications and again
existing regulations. The was lost to follow-up.
government must take aThis time,
proactive
differentiating
Vector sailed with congenital
hazardous from cargoacquired
without hypothyroidism,
the necessary however,
stance andsymptoms
provide support were persistent.
to the industryHe later
whileconsulted
exerting its at
the relationship
permits, was unseaworthy, between and washypothyroidism
manned by incompetent and the another
power to local hospital,
ensure that where
laws on he maritime
was admitted safetyandaremanaged
strictly
cardiomyopathies,
and unqualified crewmen. and the The therapeutic
Senate inquiryoptionsblamed in patientsboth as a case of anemia and bronchial asthma. He was discharged
followed.
with cardiomyopathy secondary to
ships and the government for its lack of support to thehypothyroidism. slightly improved after four days, only to have recurrent heart
The patient
shipping industry. had been
3,5,6 born full term to a then 31-year- failure symptoms,
____________ prompting admission at PGH.
old Gravida 4 Para 3 (G4P3), the
Sulpicio Lines was mandated by the government to 4th
of 9 siblings, with an Upon admission the patient was in mild respiratory
apparently unremarkable delivery
compensate the families of the victims amounting to 30,000at home facilitated by References
distress, with stable vital signs and no note of fever. Pertinent
1. Ronquillo M. Ships 20 years or older ply island routes. Philippine Daily
a traditional birth attendant. He was
pesos per family. A processing center was set up in Manila noted to be normal physical exam findings included short stature, thick lips, non-
Inquirer. 1988 Nov 1.
at birth. The patient was allegedly
by the government, manned by personnel of Sulpicio Lines at par with age both pitting
2. periorbital edema, dry
Perpena E. Sulpicio’s mariners flunked skin, a displaced
board exams. apical impulse,
Philippine Daily
physically and mentally until eight
and government workers. Though Sulpicio Lines stuck to years old when he was crackles on
Inquirer. both
1988 lung
Nov 11. fields, and bilateral non-pitting bipedal
said to
their havethat
claim stopped
passengers growing wereinlimited
height.toHe thewas
1,583brought
listed in to edema.
3. AcostaThere
O. Doñawas Pazalso a 3 cminquiry
overloaded; x 3 cm reducible
set. Philippine umbilical
Daily Inquirer.
1987 Dec 23.
a private doctor, whose diagnosis was
the manifest, representatives of the liner declared that their undisclosed, and he hernia.
4.
However, there was no pallor, no neck vein
Petilla D. Doña Paz syndrome deepens kin’s misery. Philippine Daily
distention,
was given ismedications
company willing to to increase
process theheight,
claimwhich the patient
of whoever can no apparent
Inquirer. 1988congenital
Dec 20. malformations, no cardiac murmurs
took for only one month with no improvement.
produce documents to prove their family went down with Through the and
5. no
MARINAclubbing.
ReportThere was
on the Doña also no note
Paz Tragedy. of anMaritime
Manila: anterior neck
Industry
mass. Authority; 1999 March.
years, the patient was apparently well,
the Doña Paz. In fact, the company processed claims of more although still of short
6. Session No. 29, Thirteenth Congress, Second Regular Session. Journal of
stature,
than with
3,000 thick lips,
families. Some coarse facialclaims
of these features and dry
however skin.
turned Laboratory
the Senate of workup
the Republic showed cardiomegaly
of the Philippines. with
2005 Oct 10. pulmonary
He was notably slow in ambulation.
out to be fraudulent. Some families on the other hand were He was said to have congestion,
7. National thoracic
Geographic dextroscoliosis,
Channel. and
Asia’s atheromatous
Titanic [Online]. aorta by
National
bronchial asthma at age 15 years, and
too poor to have any documents on hand. The relatives of since then he had been chest radiograph,
Geographic and
Channels left ventricular
International hypertrophy
(NGCI); 2009 by 12-lead
[cited 2010
Mar 18]. Video:
taking
the salbutamol
victims resortedtablets
to legal occasionally
remedies, includingfor boutsfiling of dyspnea
a class electrocardiogram (12-L ECG)19(Figures min.
1 andAvailable
2), normocytic from
http://www.youtube.com/watch?v=jl3ef1cambU&feature=related.
occurring
action oneThey
suit. to two timeshowever,
were, annually. unable to raise the six normochromic
8. Case Unclosed: anemia
The MV(Hgb Doña 90Pazmg/dL), dyslipidemia,
Tragedy [IOnline]. Quezon andCity,
The patient’s symptoms started
million pesos required as a filing fee. The survivors were in 2001 when he was pre-renal azotemia
Philippines: GMA (serum creatinine
Network; 2009 123Dec mmoL).
17 [cited Electrolytes
2010 Mar
reported
sent home to without
have sudden loss of consciousness.
any compensation or evenDuring post-event this on admission
18]. showed slight
Video: 15 hyponatremia,
min. hypokalemia,
Available from
http://www.youtube.com/watch?v=5F18nso5l1Y&feature=related.
time, the patient did not have any
counseling. Those who suffered injuries and received symptoms of heart failure; and
9.
hypochloremia (serum Na 136, K 3.35, Cl
Esteban R. Philippine Disaster Management System. 2004 June 3.
86). Blood gases
no prior seizures,
treatment cyanotic
in hospitals wereepisodes,
assisted chest bypain,
the headache,
company or in revealed
10. Sulpicio partially
willing tocompensated
pay victims. AFPmetabolic
News. 1987 alkalosis
Dec 23. with mild
blurring of vision. He regained consciousness
settling their medical expenses.10 Families filed cases shortly after and hypoxemia.
11. Justice The
eludes patient
kin of Doña wasPaz noted
victims. to be hypothyroid
Philippine News and based
Features.
was brought to a private physician, whose
individually hoping to get just compensation from Sulpicio assessment was a on elevated
1991 Nov 1. serum thyroid-stimulating hormone (TSH) and
“heart problem”. He was prescribed unrecalled medications markedly decreased serum free thyroxine (FT4). The exact
lines. Those who accepted the 30,000 were required to sign a
taken for a few months and eventually discontinued when values are shown in Tables 1 and 2.
waiver. Although attempts at providing enforcement
the syncopal episode did not recur. Upon admission to the wards, the patient was managed
through punitive action to accompany standing maritime
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
safety regulations have been repeatedly exerted, to this day,
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. Oral loop diuretics,
no one has been held liable for the maritime disasters that
edema. Later on this would11be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
followed after the Doña Paz.
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
correction was instituted. The sections of Endocrinology
Conclusions and Recommendations
and Cardiovascular Diseases were co-managing the patient
The sinking
Corresponding of the
author: Titanic Acelajado-Valdenor,
Ma. Czarlota pales in comparison M.D.to the
Department of Medicine together with the General Medicine service.
tragedy that is the MV Doña Paz, and a lot of factors can
Philippine General Hospital He soon developed respiratory failure, upon which the
account for the occurrence of such a tragedy, along with
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
Telephone: +632 554-8488 pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
32 ACTA MEDICA PHILIPPINA
PHILIPPINA VOL.45
VOL. 43NO.
N0. 43 2009
2011